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Waste Tire S *. ey & Inspection Reporip-Inspection Report Number <br /> 1>.CB State of California �, --^ ,-� - ■ <br /> CIWMB 181 New Survey Form Page 1 € a I ` + <br /> California Integrated Waste Management Board ,f t <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> U SS Prbte " Inspectgn Details �" a _— f ._F_� � <br /> n <br /> Site SuffiTPID Inspection Type (Fill one) <br /> x; 0 G { <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C}(1 7O C- (<!1 C1 <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name — <br /> Inspected By Inspector <br /> I o es c_ n c I-----� ljjPhysical Address `� O I ILC I_...t in 1_1 it- T <br /> �-f� Z(� M �arc�rd eve {c . <br /> Street <br /> L <br /> Inspection Date - / / / 10181 <br /> ��I, I I <br /> City <br /> f� �L� �State I ZIP Co Time In Time Out <br /> Business Rep Title _._ _ <br /> L <br /> OAM <br /> 0 PM LIJ 0 PM <br /> Operational Status Business Role tbrage Type <br /> (Fill one only) I Ii t all that apply) ,`(FIII all that apply); <br /> Active ( Passenger Q Generator (44NUtdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude ED. <br /> J LLI � 0 Hauler (� Indoor <br /> _ ! _ _ 0 0 Inactive ( Truck -� <br /> Longitude - 0 Planned �, C)TR O End-Use �ori�"Iner <br /> T <br /> Business 7" e` Ilf alf ih t a FM <br /> ,• " , " .",' "_ ` . � �`. <br /> t <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> G H <br /> ,Part B - Ins Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> p _ y <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXFJ <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 1 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Nof] <br /> ` k <br /> -�'-'-�-�- -y-ice-- �" - G 1 �C-��� C� <br /> -L2 �lr- G r1t, <br /> M C-C r , _T(AC-k _T 1 TP ' ,r < < 1 (1 t, t <br /> _CLR C_ r YI DUn ) j I t,1 ct_�ion O T ca'(er-1 ,� �o n c e-r-f_LT <br /> Inspection Form (ncludedcc 0 f <br /> Comments Included: 0 - - _3 <br /> - :,Business Rep's Signature Phone Number; .Ins ctor's Signatures _ _ _ _ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � _ � � � 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />